Pregnancy Associated Breast Changes After Nipple Sparing Mastectomy

Kristine C. Paik, BS1, Seth Z. Aschen, MD, MBA2, Alexander Swistel, MD3,Mia Talmor, MD2

1 Weill Cornell Medical College, 2 Division of Plastic and Reconstructive Surgery, Weill Cornell Medicine, 3 Division of Breast Surgery, Weill Cornell Medicine

Introduction:

• Increasing numbers of women are having children after

mastectomy, and 37% of patients diagnosed with breast

cancer and of reproductive age report wanting to have

children after completing treatment1.

• While nipple sparing mastectomy (NSM) has been shown to

have superior cosmetic results with good oncologic safety,

few data evaluate what breast exam changes women can

normally expect during a post NSM pregnancy.

• Patients often assume that since their breast tissue has

been removed, any subsequent breast changes are related

to the reconstruction. Therefore, plastic surgeons are often

the first physician consulted to evaluate physical changes

after reconstruction.

• We present our experience with patients who became

pregnant after NSM particularly with respect to breast

changes and recurrence risk to determine a pattern of

change a patient might expect to occur in order to better

counsel them with respect to further work-up, potential

treatment, and follow-up.

1 Ruddy KJ, et al. Journal of Clinical Oncology 2014;32(11);1151-1156.

Methods:

• Retrospective review of all patients that underwent NSM

and reconstruction by a single plastic surgeon at a large

academic medical center from 2007 to 2020.

• Reproductive age was defined as any patient 45 years of

age or younger at the time of NSM, and patients were

prospectively monitored to identify patients who

subsequently became pregnant.

• Various demographic, operative, tumor, treatment,

reconstructive information, as well as complications, breast

cancer recurrences, presence or absence breast exam

changes in setting of pregnancy after NSM were recorded.

For patients found to have changes on their breast exam in

the setting of pregnancy, the location, description, findings

on imaging, and any associated tissue pathology were

reviewed and documented.

• Analyses were completed using Mann-Whitney tests,

Fisher’s exact tests, and chi-squared analyses. A p-value

<0.05 was considered significant.

Results:

From 2007 to 2020, 194 patients of reproductive age underwent NSMs with subsequent

reconstruction (Fig. 2). 36 patients became pregnant after NSM and 158 patients did not

become pregnant after NSM.

There were no significant differences in tumor pathology at time of mastectomy, with majority

of cases in both groups yielding infiltrating ductal carcinoma (p=0.66). Cancer staging was

not significantly different (p=0.15). There were no significant treatment differences, with most

patients in both groups not receiving chemotherapy (p=0.80). There was no significant

difference in rates of hormonal therapy (p=0.58), nor postoperative radiotherapy (p=0.48).

Most patients in both groups had two-stage reconstruction with tissue expander placement

with final implant exchange at a later date (p>0.99). Both groups had follow-up for an

average of 4 years (p=0.65).

Conclusion:

• Breast cancer recurrence rates were not

significantly different between patients that

became pregnant and those that did not.

• Of the pregnant patients who recurred, both

presented in the second or third trimester of

their pregnancies.

• Patients who became pregnant after NSM

commonly had clinical breast exam changes

ranging from pigmentary changes of the skin to

milky or clear nipple discharge to palpable

mass. Palpable findings tended to be in the

sub-areolar and axillary areas.

• Further radiologic evaluation and biopsy results

demonstrated that majority of these changes

were found to be benign.

Significance:

• After NSM, the breast skin envelope and nipple

areolar complex with terminal ducts remain and

can continue to respond to hormonal stimuli. In

pregnancy, breast exam findings can change

due to hormonal changes, and we present our

findings for normal pregnancy associated breast

changes and changes associated with cancer

recurrence.

• Ultrasound is an appropriate first line

investigation of changes which can include

hyperplasia of remaining ductal and

glandular tissue.

• Our findings can help clinicians discuss NSM as

a cosmetically preferable and safe option for

treating breast cancer with patients who are of

reproductive age. Women should be advised to

undergo clinical follow-up with their surgeons at

the end of their pregnancies, or soon after they

deliver.